State Form 14072 – Fill Out and Use This PDF

The State Form 14072, known as the Official Indiana Animal Bites Report, is a critical document issued by the Indiana State Department of Health for the reporting of animal bite incidents. This form captures detailed information including the incident circumstances, victim and animal owner details, and the classification of the bite. If you've experienced or witnessed an animal bite incident in Indiana, filling out this form is a necessary step for official reporting and follow-up action. Click the button below to start the process of filling out the form.

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State Form 14072 PDF Details

The State Form 14072, officially titled "Indiana Animal Bites Report," serves as a vital document for the Indiana State Department of Health, meticulously recording incidents involving animal bites within the state. Crafted to ensure comprehensive documentation, this form captures crucial details ranging from the reporting agency case number and victim incident circumstances to the classification of the bite. It spans various sections that collectively gather information about the victim, the owner, and the biting animal, including demographics, vaccination status, and the extent and location of the injury. Additionally, it delves into the aftermath of the incident, exploring whether the animal was quarantined, the treatment administered to the victim, and any follow-up actions taken. This form acts as an essential tool for public health officials, facilitating effective monitoring and management of animal bite incidents to mitigate risks of rabies and other diseases. Moreover, it serves an educational purpose, emphasizing the importance of responsible pet ownership and public safety. Through its detailed classification system, the form aids in evaluating the severity of bites, ensuring that both human and animal victims receive appropriate care and interventions.

Question	Answer
Form Name	State Form 14072
Form Length	3 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	45 sec
Other names	dog bite report form for indiana, in state dept health form 47970, indiana bites report fillable', cps report form indiana

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Official Indiana Animal Bites Report

Indiana State Department of Health

State Form 14072 (R3/4-04)

Reporting Agency Case Number

Victim

Incident & Circumstances Animal Parent

Incident Location Address

Reported by (name)

Reporting Agency

Bite Classification

Reported by (phone)

(see reverse side of this page to classify)

County

Incident

Off

Property

Received by (name)

Exposure Date

Victim Type (circle 2)

Human

Animal

Juvenile

Adult

Reported Date

Reported Time

Release Date

VICTIM INFORMATION

OWNER INFORMATION

Person bitten (if animal victim, use this space for animal victim's owner):

Owner of Animal:

Last

First

Mid.

Date of Birth

Last Name

Street Address

City

Zip

Sex

Home Telephone

Work Telephone

First Name

Sex

Biting Animal

Color/Markings

Name

Sex

Date of Birth

Dog

Cat

Other

Street Address

City

Zip

Telephone

Neutered

Home:

Breed

Work:

Parent if victim is a juvenile:

Animal's Veterinarian

Prior Incidents

Last

First

Mid.

Rabies Vaccine

Date

Street Address

City

Zip

Telephone

Home:

Rabies Tag Number

License Number

Microchip Number

Citation issued?

Work:

If animal victim:

Location of Quarantine

Breed/Species

Color/Markings

Name

Vaccine Date (rabies)

Date of Quarantine

Quarantined by (name)

Release Date

Sex M F

Time of bite

Released from Quarantine by (name):

(if animal victim)

Treating Physician (or veterinarian)

Quarantined?

Name:

Owner release card (date received):

Yes No

Telephone:

Released from shelter quarantine (date):

Location on Body and Extent of Injury:

Lab #/Result:

Victim's statement of incident (animal owner if animal victim):

Animal owner's statement of incident:

Owner

Animal

Quarantine

Incident

State Department of Health required information (must be completed):

Species (fill in the correct biting species):

Bat	Dog	Hamster	Raccoon
Cattle	Ferret	Horse	Rat
Cat	Fox	Mouse	Squirrel
Chipmunk	Gerbil	Rabbit	Other

If Other, specify

Did the animal exhibit any of the following:

Convulsions Aggression Inability to eat/drink

Excessive salivation

Paralysis

Depression

Circumstances:

Animal confined (indoors, penned, tethered, or on leash) Animal not confined (stray, roaming, etc.)

Wild Animal	Provoked	Unprovoked
Unknown	Other
Action taken with animal:
No Action		Body destroyed
Escaped/not found		Head sent to ISDH Lab
Pet quarantined (see dates above)		Other
(dog, cat, ferret only)		Unknown
		Unknown

I, the undersigned, have received a copy of the quarantine guidelines, have read them, and understand them. I agree to comply with all provisions of the quarantine guidelines and understand that noncompliance may result in seizure of my pet if it is in home quarantine or loss of my pet if it is not properly claimed at the end of the quarantine period from the quarantining agency.

Witness___________________________________

Date __________________

Signature__________________________________________

DISTRIBUTION: White - Enforcing Agency, Canary - Local Health Department, Pink - Owner

State Form 14072 – Fill Out and Use This PDF

State Form 14072 PDF Details

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